Transosteal anchoring methods for tissue repair

ABSTRACT

Described herein are methods and apparatuses for use in repair of a patient&#39;s tissue by connecting the tissue to the bone using a transosteal tunnel and anchor configured to pass through the transosteal tunnel. In particular, described herein are methods of repairing an anterior cruciate ligament (ACL) and torn meniscal root. These anchoring apparatuses and method of using them are particularly well suited for use with the low-profile suture passers described herein, since these suture passers may allow access to previously inaccessible regions of the knee (or other body regions).

CROSS REFERENCE TO RELATED APPLICATIONS

This patent application is a continuation of U.S. patent applicationSer. No. 14/451,293, filed Aug. 4, 2014, titled “TRANSOSTEAL ANCHORINGMETHODS FOR TISSUE REPAIR,” now U.S. Pat. No. 9,913,638, which claimspriority to U.S. Provisional Patent Application No. 61/862,414, filedAug. 5, 2013, and titled “TRANSOSTEAL ANCHORING METHODS FOR TISSUEREPAIR,” each of which is herein incorporated by reference in itsentirety.

U.S. patent application Ser. No. 14/451,293 also claims priority as acontinuation-in-part of U.S. patent application Ser. No. 13/893,209,filed May 13, 2013, titled “IMPLANT AND METHOD FOR REPAIR OF THEANTERIOR CRUCIATE LIGAMENT,” now U.S. Pat. No. 8,888,848, which claimspriority as a continuation of U.S. patent application Ser. No.13/347,184, filed Jan. 10, 2012, titled “IMPLANT AND METHOD FOR REPAIROF THE ANTERIOR CRUCIATE LIGAMENT,” now U.S. Pat. No. 8,500,809, whichclaims priority to U.S. Provisional Patent Application No. 61/431,293,filed Jan. 10, 2011, and titled “IMPLANT AND METHOD FOR REPAIR OF THEANTERIOR CRUCIATE LIGAMENT.” Each of these patents and patentapplications are herein incorporated by reference in their entirety.

INCORPORATION BY REFERENCE

All publications and patent applications mentioned in this specificationare herein incorporated by reference in their entirety to the sameextent as if each individual publication or patent application wasspecifically and individually indicated to be incorporated by reference.

In particular, the following patent applications are herein incorporatedby reference in their entirety: U.S. patent application Ser. No.11/773,388, filed Jul. 3, 2007, titled “METHODS AND DEVICES FORCONTINUOUS SUTURE PASSING,” Publication No. US-2009-0012538-A1; U.S.patent application Ser. No. 12/291,159, filed Nov. 5, 2008, titled“SUTURE PASSING INSTRUMENT AND METHOD,” Publication No.US-2010-0331863-A2; U.S. patent application Ser. No. 12/620,029, filedNov. 17, 2009, titled “METHODS OF SUTURING AND REPAIRING TISSUE USING ACONTINUOUS SUTURE PASSER DEVICE,” Publication No. US-2010-0130990-A1;and U.S. patent application Ser. No. 12/942,803, filed Nov. 9, 2010,titled “DEVICES, SYSTEMS AND METHODS FOR MENISCUS REPAIR,” now U.S. Pat.No. 8,562,631.

FIELD

This invention relates to methods and apparatuses (including devices andsystems, as well as devices and systems for performing the methodsdescribed herein) for repair of tissue by anchoring the tissue to orwithin a bone using an anchor that is inserted almost completely througha bone before being anchored in place. In particular, described hereinare methods and apparatus for repair of the anterior cruciate ligament(ACL).

BACKGROUND

Tears to the anterior cruciate ligament (ACL) are painful and oftendebilitating. Surgery for ACL injuries typically involves reconstructingthe ACL using a graft material to replace the torn ACL. For example, ACLreconstruction surgery typically uses a graft to replace or support thetorn ligament. The most common grafts are autografts from the patient(e.g., from a tendon of the kneecap or one of the hamstring tendons),though donor allograft tissue may also be used, as well as syntheticgraft material. Although ACL reconstruction surgery is often referred toas ACL “repair” surgery, the current standard of care for ACL tears isto replace the torn ligament with a graft, rather than attempting to sewthe torn ACL together. Merely sewing together the torn ACL has provenineffective.

In general, ACL surgery may be performed by making small incisions inthe knee and inserting instruments for surgery through these incisions(arthroscopic surgery) or by cutting a large incision in the knee (opensurgery). During arthroscopic ACL reconstruction, the surgeon may makeseveral small incisions around the knee. Sterile saline solution ispumped into the knee through one incision to expand it and to wash bloodfrom the area. This allows the doctor to see the knee structures moreclearly. The surgeon then inserts an arthroscope into one of the otherincisions with a camera at the end of the arthroscope that transmitsimages of the internal region. Surgical drills may be inserted throughother small incisions to drill small holes into the upper and lower legbones where these bones come close together at the knee joint. The holesform tunnels through which the graft will be anchored. The surgeon maytake an autograft at this point. The graft may also be taken from adeceased donor (allograft). In most prior art procedures, a graft maythen be pulled through the two tunnels that were drilled in the upperand lower leg bones. The surgeon may secure the graft with screws orstaples and close the incisions with stitches or tape.

Unfortunately, replacing the ACL with a graft material, which requiresanchoring both ends of the graft material to bone, has proventechnically difficult, resulting in a long surgical time, and mayultimately require a long recovery time. Replacement of native ACLmaterial with graft material typically leads to the loss of native ACLproprioceptive fibers, and results in an alteration of the native ACLtibial footprint geometry. In some cases, removing autograft materialfrom the patient may result in donor site morbidity, while donorallograft material presents an increased risk of HIV and Hepatitis Ctransmission.

In addition, anchoring tissue to bone, both in ACL procedure and moregenerally, has proven challenging. For example, anchoring tissue to bonein regions of limited access, such as the joints (e.g., knee, shoulder,hip, etc.) without having to displace, and potentially further damage,the joints has proven difficult. Access to the bone attachment site maybe difficult in the confined region of the joint, making it particularlydifficult to manipulate and secure an anchor within this region. Onepossible solution has been drill one or more passages through the bonefrom outside of the joint to form an opening in the joint space, andthen anchor the tissue from the outside of the confined joint region,for example, by pulling the tissue, graft and/or suture through the bonepassage to the opposite side of the bone. Unfortunately, this procedureresults in poor fixation, as the tissue, graft and/or suture may stretchover time.

Thus, it would be desirable to provide devices, systems and methods forrepair of the ACL that do not require the replacement of the ACL and theformation of multiple anchoring sites. The apparatuses (systems anddevices) and methods for repair of the ACL described herein may addressthese concerns.

SUMMARY OF THE DISCLOSURE

The present invention relates to apparatuses and methods for repair oftissue (including, but not limited to ACL) using an anchor that may bepassed through a tunnel from a first opening on a first side of the bonechannel to an opposite side of the bone tunnel. The anchor may be usedwith a graft material that may be sutured directly onto the torn tissue.The systems and methods described herein may use a suture passerconfigured to operate in the narrow confines of a bone joint, includingthose having independently operable sliding and bending jaws with acompletely retractable tissue penetrator, such as those described inmany of the applications previously incorporated by reference in theirentirety, including at least: U.S. patent application Ser. No.11/773,388, filed Jul. 3, 2007, titled “METHODS AND DEVICES FORCONTINUOUS SUTURE PASSING,” Publication No. US-2009-0012538-A1; U.S.patent application Ser. No. 12/291,159, filed Nov. 5, 2008, titled“SUTURE PASSING INSTRUMENT AND METHOD,” Publication No.US-2010-0331863-A2; U.S. patent application Ser. No. 12/620,029, filedNov. 17, 2009, titled “METHODS OF SUTURING AND REPAIRING TISSUE USING ACONTINUOUS SUTURE PASSER DEVICE,” Publication No. US-2010-0130990-A1;and U.S. patent application Ser. No. 12/942,803, filed Nov. 9, 2010,titled “DEVICES, SYSTEMS AND METHODS FOR MENISCUS REPAIR,” now U.S. Pat.No. 8,562,631; U.S. patent application Ser. No. 13/462,773, filed May 2,2012, titled “SUTURE PASSER DEVICES AND METHODS,” now U.S. Pat. No.8,465,505; and U.S. patent application Ser. No. 13/323,391, filed Dec.12, 2011, titled “SUTURE PASSER DEVICES AND METHODS,” Publication No.US-2012-0283753-A1.

Although the methods and apparatuses described herein may be used torepair a torn anterior cruciate ligament (ACL), these methods andapparatuses are not limited to ACL repair, but may be generallyapplicable and used to repair tissue, and particularly tissue within aconstricted region of the body (including joints) that would benefitfrom attachment to a bone. Thus, although the examples described hereinillustrate ACL repair, it should be understood that any tissue, graft,or implant may be repaired using these methods and apparatuses. Forexample, repair of torn ligaments in the shoulder, hip, spine, or thelike, including, without limitation, repair of the rotator cuff repair.

In general, the methods described herein may be referred to astransosteal because they may include the step of forming a passage,channel, tunnel, or the like (which may be referred to as a “tunnel” forconvenience) through a bone (such as, for example, a femur head) from afirst side of the bone to a second side of the bone, and passing ananchor through the tunnel from either the first side or the second sideand all the way through the bone passage to the opposite side where itis anchored in place. The suture may be cinched in the anchor by pullingfrom the first side of the bone when the anchor is located on the secondside of the bone. The bone anchor may be adapted for both passingthrough the tunnel and for anchoring into the bone after passing throughthe tunnel. The bone anchor may be referred to as a transosteal boneanchor (and/or suture anchor). A transosteal bone anchor may include apassageway through the anchor (e.g., along the length of the anchor) sothat a suture, graft, and/or tissue may be pulled through the anchor andcinched in place. Thus, the suture anchor may include one or morelocking elements (e.g., one-way locks) to permit suture, graft and/ortissue to be drawn into the anchor, but prevent the suture, graft and/ortissue from exiting the anchor.

For example, described herein are methods for transosteally repairing atissue that include the steps of: forming a tunnel through a bone sothat the tunnel extends from a first side of the bone to a second sideof the bone; passing a suture anchor through the tunnel from the firstside of the bone, through the tunnel and adjacent to the second side ofthe bone; securing the suture anchor within the tunnel adjacent to thesecond side of the bone; securing a torn end of the tissue to a suture;and cinching the suture in the suture anchor by pulling the suturethrough the anchor from the second side of the bone and out of the firstside of the bone.

The method may also include securing the torn end of the tissue to agraft coupled to the anchor.

In some variations, forming a tunnel comprises drilling an elongate,straight tunnel through the bone. The tunnel may include a first opening(into the bone) on the first side of the bone, and a second opening(into the bone) on a second side of the bone. In general, the tunnel isstraight, however the tunnel may also be curved. The anchor and tunnelmay be configured to complement each other, so that the suture anchormay be configured for transit through the tunnel from a first side ofthe bone to the second (opposite) side of the bone. The tunnel and/oranchor may be sized and configured so that the anchor may pass throughthe tunnel until reaching the second side of the bone, wherein theanchor may be secured in position. For example, the tunnel may betapered or may include a smaller second opening than first opening.

Any of the methods or apparatuses described herein may include atransosteal bone anchor that includes one or more elements to help theanchor stay fixed at or near the second end of the tunnel. For example,the anchor may be threaded or may include one or more projecting membersthat are configured to project from the anchor and engage the wall orwalls of the tunnel. In some variations the wall of the tunnel may beadapted to receive one or more members from the anchor. For example, thewall of the tunnel may include an indentation, cavity, notch, or thelike to receive a extending member from the anchor once the anchor is inposition; the extending member from the anchor may be biased to openwhen the anchor is in position, pushing (extending) the extendingmembers into the receiving region(s) and preventing the anchor frommoving within the tunnel once in position. For example, securing thesuture anchor within the tunnel adjacent to the second side of the bonemay comprise extending one or more locking arms from the suture anchoronce it has been positioned adjacent to the second side of the bone.

In some variations, the anchor is advanced in the tunnel and/or securedin the tunnel by screwing the anchor into the tunnel. In somevariations, the tunnel may be threaded over all or a portion of itslength (e.g., all except the portion near the second side of the bone.

In general, the tunnel may be formed by drilling. For example, forming atunnel may comprise drilling an elongate, straight tunnel through thebone from the first side of the bone to the second side of the bone. Insome variations the method may be performed with a guidewire. Theguidewire may be used to form the tunnel and/or to place the anchor,and/or to draw the suture through the anchor and/or tunnel. For example,forming a tunnel may comprise driving a guidewire through the bone fromthe first side of the bone to the second side of the bone. The guidewiremay be a needle or rigid wire. The guidewire may couple or connect to asuture and/or anchor.

In some variations, passing a suture anchor may comprises passing asuture anchor having a central passageway configured to permit a sutureto be pulled in a first direction while preventing the suture from beingpulled in a second direction that is opposite to the first direction.

In some variations, securing the suture anchor within the tunneladjacent to the second side of the bone comprises securing the sutureanchor within the tunnel so that a distal end of the suture anchorextends from the second side of the bone; alternatively, the sutureanchor may be secured so that the suture anchor is recessed within thetunnel relative to the second side of the bone; alternatively, thesuture anchor may be secured so that an end of the suture anchor isflush with the second side of the bone.

The step of securing a torn end of the tissue to a suture may compriseprecutaneously suturing the torn end of the tissue with a suture passernear the second side of the bone. In general, a suture passer such asthose discussed and described herein may be used to precutaneouslysuture the torn tissue. For example, a suture passer may be configuredwith a first jaw that is slideable relative to the second jaw, and thesecond jaw may be hinged to pivot relative to the first jaw and/or theelongate body of the suture passer. In a retracted configuration, withthe first jaw retracted proximally relative to (and/or into) theelongate body of the suture passer, the second jaw may be angled toallow a high degree of maneuverability within a confined tissue regionsuch as a joint that is at least partially surrounded by bone. The firstjaw member may be extended after placing the second jaw adjacent to thetarget tissue, so that the first and second jaws may form an open,distal-facing mouth around the target tissue to pass a suture betweenthe first and second jaws.

In general, the suture, and particularly the end of the suture extendingfrom the anchor toward the first side of the bone, may be trimmed orcut. The thus, in some variations, the method may comprise cutting theend of the suture extending from the first side of the bone.

In general, the tunnel through the bone may be filled and/or closed offafter cinching and securing the torn tissue (e.g., ligament) in or tothe bone. For example, any of the methods described herein may include astep of filling the tunnel through the bone after cinching the suture inthe anchor. The tunnel may be filled with bone cement (e.g., poly methylmethacrylate), and/or bone chips, or the like.

Also described herein are methods of repairing torn anterior cruciateligaments (ACL). For example, described herein are methods for thetransosteal repairing a torn anterior cruciate ligament (ACL), themethod comprising: forming a tunnel through a femur so that the tunnelextends from a first side of the femur to a second side of the femur;passing a suture anchor through the tunnel from the first side of thefemur, through the tunnel and securing the suture anchor near the secondside of the femur; securing a torn end of the ACL to a suture; andanchoring the suture in the suture anchor by pulling the suture throughthe anchor from the second side of the femur and out of the first sideof the femur, wherein the anchor comprises a one-way lock configured toprevent the suture from pulling out of the anchor toward the second sideof the femur.

Also described herein are methods for transosteally repairing ananterior cruciate ligament (ACL) within the femoral notch, the methodcomprising: forming a tunnel through a femur so that the tunnel extendsfrom a first side of the femur to a second side of the femur within thefemoral notch; anchoring a suture anchor within the tunnel and adjacentto the second side of the femur; securing the suture anchor within thetunnel adjacent to the second side of the femur; securing a torn end ofthe ACL to a suture; and cinching the suture in the suture anchor bypulling the suture through the anchor from the second side of the femurand out of the first side of the femur, wherein the anchor comprises aone-way lock configured to prevent the suture from pulling out of theanchor toward the second side of the femur.

For example, described herein are methods for repairing a torn ACLwithin the femoral notch. In some variations, the methods include thesteps of: anchoring a graft within the femoral notch; and suturing atorn end of the ACL to the graft within the femoral notch. In general,the step of anchoring the torn end of the ACL to the graft is performedprecutaneously. The graft may be integral to (or pre-attached to) ananchor such as a knotless anchor. In some variations the torn end of theACL is twice anchored within the femoral arch: both to a suture passedthrough and/or around the torn end of the ACL, and then to a graft thatis anchored within the ACL. The connection to the graft may be madesecond, so that it may reinforce the suture which can be secured withinthe ACL to the same (or in some variations a different) bone anchor.

For example, in some variations, the step of anchoring a graft comprisessecuring an anchor to which a graft has been coupled within the femur sothat a proximal end of the graft extends from the femur. For example,anchoring a graft may comprise driving a guidewire through the femur anddrilling an opening to hold a graft anchor; and securing an anchorcoupled to a graft within the opening over the guidewire.

The anchor may be secured by screwing the anchor into the opening (e.g.,the tunnel drilled through a region of the femoral notch).

In some variations, the method includes securing the torn end of the ACLto a suture and pulling the suture through the femur to position thetorn end of the ACL adjacent to the graft. The step of suturing the tornend of the ACL may comprise passing a suture through the graft and theACL multiple times, e.g., with a suture passer that is adapted for usewithin the narrow confines of the tissue. For example, the step ofsuturing the torn end of the ACL may comprise passing a suture throughthe graft and the ACL multiple times with a continuous suture passerwithout removing the suture passer from the tissue.

In some variations the method further comprises securing the torn end ofthe ACL to a suture and pulling the suture through the femur toanatomically tension the ACL adjacent to the graft.

Also described herein are methods for repairing a torn ACL within thefemoral notch, the method comprising: anchoring a graft within thefemoral notch; positioning a torn end of the ACL adjacent to the graft;and percutaneously suturing the torn end of the ACL to the graft withinthe femoral notch.

In some variations, the step of positioning comprises securing a sutureto the torn end of the ACL. For example, pulling the suture through atunnel in the femoral notch to position the torn end of the ACL adjacentto the graft. In some variations, the method includes the step ofanchoring the torn end of the ACL to the femoral notch with a suturebefore percutaneously suturing the torn end of the ACL to the graft.

In any of the variations of methods described herein, the method mayinclude forming (e.g., drilling) a tunnel through the femoral arch foranchoring the torn ACL. The step of anchoring the graft within thefemoral notch may include anchoring the graft within a tunnel drilledthrough the femoral arch.

Also described herein are methods for repairing a torn ACL within thefemoral notch, the method comprising: drilling a tunnel through aportion of the femoral notch; anchoring a graft within the tunnelthrough the femoral notch, wherein the graft extends from the tunnel;pulling a suture connected to a torn end of the ACL through the tunnelthrough the femoral arch to positioning the torn end of the ACL adjacentto the graft; anchoring the suture connected to the torn end of the ACL;and percutaneously suturing the torn end of the ACL to the graft withinthe femoral notch.

BRIEF DESCRIPTION OF THE DRAWINGS

FIGS. 1A and 1B show one variation of a knotless ACL repair screw(anchor) as described herein.

FIG. 1C shows another variation of a knotless anchor that may be used.

FIGS. 2A-2D illustrate one method of loading a suture into a knotlessACL repair screw such as the variation shown in FIGS. 1A-1B.

FIGS. 3A-3P illustrate one method of repairing an ACL using a knotlessACL repair screw.

FIGS. 4A-4D illustrate one method of securing an ACL (e.g., a torn ACL)to a suture as described herein.

FIG. 5 shows another variation of a knotless ACL repair screw.

FIG. 6 shows another variation of a knotless ACL repair screw.

FIGS. 7A and 7B show another variation of a knotless ACL repair anchor.

FIG. 8A shows one variation of a suture passer that may be used with themethods and apparatuses described herein. In this example, the lower jawmember is retracted (into the elongate shaft) and the pivoting upper jawmember is bent up at a 30° angle relative to the elongate shaft.

FIGS. 8B and 8C show top perspective and side views, respectively, ofthe distal end of the suture passer of FIG. 8A; in this example, thelower jaw is fully extended axially to form a distal-facing opening(“mouth”) with the pivoting upper jaw. The pivoting upper jaw may pivotrelative to the proximal elongate shaft body to which it is connected.

FIG. 8D shows a side view of the distal end of the device of FIGS.8A-8C, with the tissue penetrator (needle) extended across thedistal-facing opening; the tissue penetrator may be used to push and/orpull a suture between the jaws and through tissue held (e.g., clamped)between the upper and lower jaws.

FIGS. 9A and 9B illustrate arthroscopic spatulas that may be used forknot typing and instrument insertion during any of the methods describedherein.

FIGS. 10A-10K illustrate another variation of a transosteal method forrepair of a tissue.

FIG. 11A illustrates an alternative method for repair of a tissue (e.g.,ACL) similar to the method shown in FIGS. 10A-10K.

FIG. 11B shows another variation of an anchor that may be used fortransosteal repair.

FIG. 12A illustrates an example of a torn meniscal root of a knee; FIG.12B shows a transosteal tunnel formed through the tibia beneath the tornmeniscal root. FIGS. 12C and 12D show positioning and securing an anchornear the tibial plateau after inserting from the opposite side of thetibial tunnel.

FIGS. 13A-13E show one variation of meniscal root repair using a doublelocking loop stitch.

FIGS. 13F and 13G illustrate an alternative method of securing tissue(e.g., meniscal root) in which a simple stitch is used as well as alocking loop stitch to secure the tissue.

FIGS. 13H and 13I show another variation of a method of securing tissue(e.g., meniscal root) in which a simple stitch is used with a lockingloop to secure the tissue.

FIGS. 14A-14E show another variation of a meniscal root repair.

DETAILED DESCRIPTION

In general, described herein are methods and apparatuses for repairing atorn tissue, including transosteal methods of repairing a torn tissue.These methods may include the steps of forming a channel through a bonethat extends from a first side of the bone to an opposite (second) sideof the bone, securing an anchor in the tunnel at or near the second sideof the tunnel, percutaneously suturing the torn tissue to secure thesuture to the torn end of the tissue, and pulling the suture and torntissue toward the anchor, though an opening in the anchor and/or tunnelfrom the second end of the tunnel toward the first end of the tunnel,thereby securing the suture and/or tissue within the bone tunnel and/oranchor. In particular, these methods may include securing the anchor bypassing the anchor though the tunnel from the first side of the bone to(or near) the second side of the bone. This method may allow minimallyinvasive repair of torn tissue and/or implantation of grafts or othermaterials, even in very narrow or confining spaces such as bone joints,without having to distend or otherwise open up the space and potentiallydamage the surrounding tissue, as is currently required in many tissuerepairs.

For example, described herein are methods and devices for use in repairof a patient's anterior cruciate ligament (ACL). These methods (anddevices for performing them) allow the repair, rather than merelyreplacement, of the ACL. As discussed above, although the ACL is used toexemplify the apparatus and methods of the present invention, theseapparatuses (devices and systems) may also be used with many othertissues and are not limited to the repair and/or replacement of ACLtissue.

The anchoring devices described herein may be inserted into a bone andmay hold a graft material within the bone so that the graft may also beattached to the torn or damaged ACL. The implanted anchoring device(which may also be referred to as an “implant” or “knotless graftanchor” or “suture anchor”) may be particularly well suited for use withany of the low-profile and/or continuous suture passers describedherein, since these suture passers may allow access to previouslyinaccessible regions of the knee (or other body regions). For example,the methods described herein may include access into the notch region(e.g., the femoral notch) to anchor a graft in an optimal position, andto suture the graft to the damaged ACL while maintaining as much of thenative ACL as possible. Previous methods of “repairing” (rather thanreplacing) the ACL have proven unsuccessful at least in part becausethis region was difficult or impossible to successfully access. Suturingin the notch region, without the benefit of the continuous suturepassers described and incorporated by reference herein, has provenextremely difficult and time consuming, discouraging such surgicalrepairs.

In variations including a graft material, any appropriate graft materialmay be used. For example, an ACL graft for use with the methods anddevices described herein may include: synthetic grafts (e.g., Gore-Tex,Dacron, carbon fibers, and polypropylene braids, etc.), biologic (e.g.,porcine, human or other) allografts, autografts, etc. The graftmaterials describe herein may provide support or scaffolding for repairof the torn ACL, since the ACL is left in place and sutured to thegraft. Thus, in some variations the graft may be a sleeve or patch(e.g., a graft jacket, Restore patch, etc.) The graft may include abiologic material such as a growth-promoting material that may promotein-growth, visualization, or the like (e.g., growth factors, etc.).

In general, the apparatuses (e.g., devices and/or systems) describedherein may include a knotless anchor, such as a knotless ACL graftanchor, which may also be referred to as an ACL graft anchor, a one-wayACL graft anchor, a knotless ACL repair screw, or merely a “device” inthe description below. These ACL graft anchors are one type of anchorthat may be used, and (like other types of anchors) may include aone-way path for passing (and therefore anchoring) a suture. The ACLgraft anchor may also include a coupling region for coupling to a graftmaterial. Any of the anchors that may be used for the proceduresdescribed herein (including, but not limited to, the ACL anchors) mayinclude a one-way path may be a central passage through the device. Ingeneral a one-way path forms a channel through the device and mayinclude cams or other locking members that prevent a suture passingthrough the one-way path from pulling out the device. The one-way pathmay be referred to as the suture channel or path, since the suture mayextend through (and be held within) the one-way path, although otherelements (e.g., a guidewire, such as a beath pin, etc.) may also bepassed through the channel. The one-way channel may extend from theproximal to the distal ends of the device, which may advantageouslyallow the anchor to be easily implanted and positioned, and may anchorthe suture (e.g., connected to an ACL) at or within a bone region of thefemoral notch. For example, the suture may be drawn through the implantto pull the distal end portion of a torn ACL towards (and to or into)the proximal end of the anchor. The anterior end of the implant istypically the end that faces the torn tissue, and may not be completelyinserted into the bone, and may face away from the bone.

As mentioned above, some variations of the anchors described hereinallow both securing (e.g., suturing) of the torn ACL to thescaffold/support (e.g., graft) after the graft has been anchored intothe bone, and also tensioning of the torn ACL by pulling and locking theposition of a suture that has been secured to the torn end of the ACL.In particular, the anchor includes a one-way pathway that allows thesuture connected to the torn end of the ACL to be pulled and held(locked) distally, to adjust the tension on the ACL as it is beingpositioned adjacent to the graft so that it can then be sutured to thegraft. The one-way locking mechanism in the suture pathway through theanchor allows this tensioning. Thereafter, the reinforcing support ofthe graft (scaffolding) maintains the tension and position of the ACLfor short-term repair and long-term healing. Thus, described herein areanchor devices that are configured to both pre-tension a torn ACL and tosecure the tensioned ACL to the reinforcement graft anchored in the boneby the device. Some variations of these devices therefore may include aone-way (locking) path for a suture to be drawn through the body of theanchor as well as a coupling region for a graft, or a graft that isalready integrally part of the device.

The coupling region that may couple to a graft may be located as thedistal end (e.g., the end to be inserted into the bone) of the device sothat the graft will be anchored at one end in the bone. The couplingregion may be positionable or rotatable around the circumference of thedevice. In some variations the coupling region is a loop or ring that isrotatably attached around the distal end region of the ACL anchor, whichis also connected to a second loop or ring through which the graft(e.g., ACL graft) may pass and be secured. A coupling region may bereferred to as a collar. Alternatively, the attachment region mayinclude a suturing substrate (e.g. fabric) to which the graft may becoupled or connected. In some variations, the coupling region mayinclude a passage through the device through which the graft may bepassed. In some variations the coupling region is connected (or formedof) the distal end of the ACL anchor, which may be rotatable around thelong axis of the ACL graft anchor.

Thus, in general, the ACL anchors described herein are configured tosecure both an ACL graft (which is to be sutured to the ACL) and asuture that is also connected to the torn ACL.

The ACL anchors described herein may also be configured to secure withinan opening drilled into the bone (e.g., a tunnel into the bone, as shownin the figures and discussed below). The sides of the anchor may beself-tamping, ridged, expandable, or the like, to secure the anchorwithin the bone. The body of the anchor may also include one or morepassages or opening into which bone may grow (or be encouraged to grow).In some variations the device includes lateral openings into which across-pin or other additional anchoring device may be inserted.

For example, FIGS. 1A and 1B show one variation of an anchor, configuredas a knotless ACL repair screw (ACL graft anchor). In this example theACL graft anchor has a screw-shape body (e.g., a threaded body) thatextend in a proximal-distal longitudinal direction. The distal endincludes a distal collar for attachment to a graft material; the distalcollar (coupling region) includes a loop through which the graftmaterial may pass and be secured, and a collar region surrounding anopening at the distal end. Thus, the collar can rotate relative to thebody of the device. This allows the threaded, screw-shaped body to bescrewed (rotated) into position within the bone, while the graft at thedistal end may remain in the same position (e.g., on one side of thebody). In FIG. 1A, the distal collar can rotate freely with respect tothe screw (body of the anchor), and has an eyelet through which anyreinforcement graft or allograft can be inserted (e.g., a graft jacket,Restore Patch, tibialis anterior allograft, etc.).

Other examples of anchors that may be used may not include the graftattachment region, but may be otherwise similar. For example, the anchormay include threaded sides and a central channel with a one-way lockingmechanism for the suture. In some variations it is not necessary to usea graft to secure the torn tissue (e.g., ACL) within the anchor andtherefore the bone; the torn tissue may be directly sutured as shown anddescribed below (e.g., FIGS. 4A-4D), and the suture secured to theanchor.

An ACL repair screw (anchor) body such as the one shown in FIG. 1A maybe made out of relatively strong and biocompatible material, such asPEEK. In this example, the outer body region is threaded for screwinginto a channel made in the bone. The device includes a central channelthat creates a one-way passage for a suture, and can thereby anchor asuture in position. For example, the central channel may include tabsthat create a one-way pathway for a suture. In other variation thesuture is allowed to pass only in one direction (e.g., towards thedistal end of the implant) by tabs, clamps, cams, ball valves, checkvalves, or the like).

FIG. 1B shows the device of FIG. 1A with exemplary range of dimensions(e.g., length of approximately 15-20 mm, and width of approximately 3-8mm). In some variations, a smaller diameter screw may be beneficialbecause a smaller diameter screw will allow more contact of the ligamentto bone at the repair site.

FIG. 1C shows another variation of an anchor, similar to the anchorshown in FIGS. 1A-1B, but without the external graft attachment. In thisexample, the anchor may be screwed into the bone (e.g., into a tunnelformed through the bone). The anchor may include an attachment site (notvisible in FIG. 1C) for connecting to an applicator or holder. Theattachment site may be located at one end (e.g., the distal end 115) ofthe anchor and may hold the anchor so that can be screwed into the bone.The attachment site may be internal threading or other releasableattachment. In some variations, as described below, the anchor may bescrewed from a first side of the bone into the tunnel drilled throughthe bone until the anchor; e.g., the proximal end of the anchor 113 mayextend slightly from the second bone surface, or it may be flush withthe bone surface, or it may be recessed slightly (e.g., a few mm orless) relative to the bone surface.

FIGS. 5 to 7B, 10G-10K and 11B also illustrate alternative variations ofanchors that may be used with the systems and methods described herein.For example, in FIG. 5, the anchor includes a central one-way path for asuture that is locked in place by a ball valve. In FIG. 6, the anchoralso includes a passageway completely through the anchor, and includesmultiple projecting “arms” or tabs (e.g. locking arms) that extend fromthe anchor body and may be collapsed against the tunnel wall as theanchor is advanced through the tunnel, but the arms may expand outwardswhen reaching the position near the second wall of the bone; a lip,recess, or other region may be formed in the bone to hold the lockingarms in place. The arms may be oriented to prevent the anchor frompulling out (e.g., in the direction of the torn tissue). In somevariations the arms may be “released” once the device is positionedwithin the cavity, so that the anchor may be readily implanted in thebone by driving it down (through) a bone tunnel from an outer wall ofthe bone to the inner wall of the bone (the wall facing the torn tissueto be repaired).

A passageway for the suture and/or tissue (and/or graft) through theanchor may also be valved to allow only one-way travel through thedevice, as shown. In FIG. 5, the embodiment shown includes a sutureforming a loop at the distal end, which may be connected to a tissue(e.g. an ACL) so that the tissue may be drawn towards and anchored intoposition relative to the anchor. FIGS. 4A to 4D, described in greaterdetail below, illustrate securing the end of a tissue such as an ACL toa suture so that it can be loaded into a knotless anchor.

FIGS. 7A and 7B illustrate another variation of an ACL anchor in whichthe anchor secured itself into position within a hole or opening in thebone. This design may allow for a smaller hole to be made in the bone(e.g., the bone forming the notch region). In this example, as shown inFIG. 7A, the implant (with a one-way passage) is inserted into a passagein the bone as shown. In this example, the scaffold material (e.g.,graft) is not shown, but may be included. Once in position, the anchormay be locked in place by expanding at least a region of the implant.For example, in FIG. 7B, the proximal end of the device expands outwardsagainst the walls of the opening or passage in the bone, locking it inplace, as shown. A suture (not shown) may be pulled through the one-waypassage in the anchor, to draw the ACL towards the device, andpotentially into the bone. The ACL may then be secured in position andso that in-growth can help anchor it in place. In some variations, theanchor includes a cam or camming mechanism that may create a one-wayanchor within the channel for the suture.

As mentioned above, any appropriate suture passer may be used,particularly those described in: U.S. patent application Ser. No.11/773,388, filed Jul. 3, 2007 and titled “METHODS AND DEVICES FORCONTINUOUS SUTURE PASSING,” Publication No. US-2009-0012538-A1; U.S.patent application Ser. No. 12/291,159, filed Nov. 5, 2008 and titled“SUTURE PASSING INSTRUMENT AND METHOD,” Publication No.US-2010-0331863-A2; Ser. No. 12/620,029, filed Nov. 17, 2009, titled“METHODS OF SUTURING AND REPAIRING TISSUE USING A CONTINUOUS SUTUREPASSER DEVICE,” Publication No. US-2010-0130990-A1.” For example, suturepassers having a suture shuttle that is configured to clamp to the sideof a curved tissue penetrator that can be extended and retracted to passthe suture shuttle (and any attached suture) back and forth between twoopen/closed jaws or arms are of particular interest. In this example,the suture shuttle may generally include a shuttle body that clamps tothe tissue penetrator, and has an extension region (“leash”) with asuture attachment region at the end. In this way the suture may be heldslightly apart from the tissue penetrator, and not interact directlywith the tissue penetrator.

In some variations, the shuttle used for passing the suture by acontinuous suture passer may be further adapted for use with the devicesand methods described herein. For example, the shuttle may be configuredto include a lead wire that allows a region of one or more loop to becut free after the initial ACL suture is placed (because the centralpart of the suture may be passed to allow a loop to be formed, throughwhich the proximal aspect of the suture ends can be inserted for aself-cinching pattern. See, for example, FIGS. 4A-4D. FIGS. 8A and 8Billustrate variations of suture shuttles including multiple (two in thisexample) loops extending from the body of the suture shuttle. The outerloop may be cut away, broken or otherwise opened to release a suture orloop of suture. The same suture shuttle may the then be used againwithout having to remove it from the tissue, and without having to drawone or both free ends of the suture out of the loop.

In any of the variations described herein, one or more arthroscopicdevices may be used to help manipulate the tissue, in addition to thesuture passers (or in place of the suture passers) described. Forexample, FIGS. 9A and 9B illustrate two variations of arthroscopicspatulas that may be used for knot typing and instrument insertion, asappropriate.

In general, any of the anchors described herein may be used as part of asystem for repairing ACL. Such a system may also include a continuoussuture passer and or suture material. In particular, continuous suturepassers that are capable of passing a suture back and forth (e.g., byconnection to a shuttle member) between two arms or jaws while the jawsare open around the tissue (e.g., ACL tissue), are of particularinterest. Thus, the system may include the suture passer, and one ormore anchors as described herein. For example, the suture passers mayinclude one such as that illustrated in FIGS. 8A or 8B.

FIG. 8A-8D illustrates one variation of a suture passer that may be usedto secure a suture to a tissue, such as a torn ACL. A suture passer suchas the suture passer shown in FIG. 8A may also be adapted to suturetissue using one or more lengths of suture that includes a knot, so thatthe knot is passed through the tissue by the suture passer.

The suture passer of FIG. 8A has a tissue penetrator that is housedwithin (with the distal tip within) the lower jaw but, when extendedacross the distal opening formed between the upper and lower jaw,extends distally from a distal opening in the upper jaw. The tissuepenetrator travels in a roughly sigmoidal path from the lower to upperjaw, meaning it is deflected twice: first from the lower jaw to extendacross the opening, and then by the upper jaw to extend distally out ofthe upper jaw. In some variations, two lengths of a suture (includingtwo lengths of the same suture, e.g., two ends of the same suture) canbe loaded into the lower jaw and sequentially passed from the lower jaw,through different regions of the tissue and retained in the upper jaw,to pass a length of suture through the tissue. The suture passer show inFIGS. 8A-8D is also configured so that the upper jaw member can pivot toassume a different angle relative to the elongate body of the device,and the lower jaw member is axially extendable distally from the distalend of the elongate member to form a distal-facing mouth with the upperjaw member. The proximal handle includes a plurality of controls forcontrolling the pivoting of the upper jaw member, the axial sliding ofthe lower jaw member, and the extension/retraction of the tissuepenetrator from the lower jaw member.

For example, FIG. 8A shows the suture passer with the lower jaw fullyretracted (relative to the upper jaw) into the elongate shaft. Thehandle includes controls for operating the upper jaw(pivoting/scissoring), lower jaw (extending/retracting or sliding), andtissue penetrator (passing the suture between the upper and lower jaws).In FIG. 8A, the proximal handle control 805 is configured as a triggeror lever that controls the motion of the upper jaw member (“upper jawcontrol”). The upper jaw control may be pulled to reduce the angle ofthe upper jaw relative to the long axis of the elongate member 807. Inthis variation the upper jaw control is pinned and allowed to drive atendon in the elongate member distally when compressed to drive theupper jaw down (reducing the angle between the upper jaw and the longaxis of the elongate member). This pivoting motion may also be referredto as scissoring (scissoring motion).

A second control 813 (“lower jaw control”) is also configured as a leveror trigger, and may be squeezed or otherwise actuated to extend and/orretract the lower jaw 806 to form a distal-facing mouth with the upperjaw, as shown in FIG. 8B. In some variations the lower jaw control isfurther configured to control deployment of the tissue penetrator 822 toextend and retract across the distal-facing opening 833 formed betweenthe upper and lower jaws. For example, in some variations squeezing thelower jaw control after completely extending the lower jaw may deploythe tissue penetrator from the lower to the upper jaw so that the distalend 825 of the tissue penetrator extends out of the upper jaw. As itextends between the upper and lower jaw, the tissue penetrator may carrya first length (bight) of suture through the tissue. Upon reaching theopposite jaw member, the suture may be removed from the tissuepenetrator and held (e.g., by a stripper) in the upper jaw. Upon releaseof the distal control, the tissue penetrator may withdraw back into thelower jaw. If the user would like to send a second length of suturethrough the tissue (e.g., after moving the jaws relative to the tissue),actuating (e.g., squeezing) the distal control 813 again may result inthe extending the tissue penetrator (along with any second length ofsuture) back through the tissue from the lower jaw to the upper jaw,where the second length of suture can be retained. Alternately, in somevariations, the controls (e.g., to control motion of the upper and/orlower jaw) may be separate from each other, and/or fromextending/withdrawing the tissue penetrator. Additional controls mayalso be included in the proximal handle, include a suture loadingcontrol (e.g., switch, toggle, etc.) for loading and/or tensioning thesuture within the lower jaw member. In some variations the deviceincludes a release control for releasing the clamp element/sutureretainer on the upper jaw. Thus, a loop of material can be left behindin the tissue after withdrawing the suture passer. Alternatively, a loopof suture may be pulled out and through the tissue and the suturemanually uncoupled from the upper jaw.

FIGS. 8B-8D show an enlarged view of the distal end of the device ofFIG. 8A. For example, in FIGS. 8B and 8C the upper jaw 803 is thin andslightly radiused (e.g., curved), and is hinged to the elongate shaftregion of the device. The upper jaw is also connected to a control onthe proximal handle by a push/pull member (tendon, wire, rod, etc.),allowing adjustment of the angle of the upper jaw member relative to theelongate member. The upper jaw may also be used to “clamp” tissue to adesired and controllable amount when suturing.

In addition to the suture passers described above, including in FIGS.8A-8D, the apparatus (e.g., systems) for repairing tissue describedherein may also include one or more tools for forming a tunnel, and/orhole or opening in bone into which an anchor may be positioned, and aguidewire, needle or pin that may be useful for inserting the anchor,guiding the formation of the tunnel, and/or for threading a suturethrough the anchor. Additional manipulation tools, including those shownin FIGS. 9A and 9B, may also be included.

EXAMPLE 1 Method of Repairing ACL

In set of examples of transosteal methods as described herein aremethods of repairing a torn ACL. These methods may include anchoring oneend of an anchor (which may include a graft or scaffold) in the femoralnotch, for example, by securing an anchor in the femur at the attachmentsite of the ACL to the bone in the femoral notch. The anchor may holdone end of a flexible scaffold for attaching to the patient's ACL. Thescaffold may be a graft, sleeve, patch, or the like. The step ofanchoring may include anchoring a scaffold (e.g., graft) using an ACLgraft anchor such as those described above. The scaffold may be securedby first driving a pin (e.g., a beath pin) though the posterolateralfemoral arch, and drilling an opening into which the ACL graft anchormay sit. In some variations a second tunnel or passage for the graft,adjacent to the first, may also be formed. An ACL graft anchor with anattached ACL scaffold may then be secured into the opening formedthrough the femoral arch bone. In some variations a guidewire may beused to guide both the drill and/or the anchor so that it can bepositioned.

In some variations, as illustrated below, the anchor may be inserted inthe desired location by first forming a tunnel through the bone (e.g.femur) and then driving or otherwise pushing the anchor from the outer(first bone) wall which faces away from the torn tissue (e.g., away fromthe femoral notch) thought the bone in the tunnel so that the anchor ispositioned near the inner (second) wall of the bone, facing the femoralnotch and the torn ACL tissue. The anchor may be positioned so that itis recessed, flush, or extends slightly from the second wall of the bonein the femoral notch. In variations in which the scaffold (e.g., graft)is attached to the anchor before positioning it in the bone, the graftand anchor may together be driven through the bone tunnel to the secondbone wall. For example, the anchor may be adapted to hold the scaffoldwithin a central region or channel of the anchor so that the scaffoldcan be extended from the anchor for attachment to the tissue once theanchor has been positioned.

In variations using a scaffold, once the scaffold (e.g., graft) isanchored in the femoral arch, the torn end of the ACL, when repairingthe torn ACL, may be pulled towards the ACL anchor and scaffold andsutured to the scaffold while in the notch. For example, the end of thetorn ACL may be sutured or connected to a suture and the suture drawnthough the body of the suture anchor to pull the end of the ACL towardsthe anchor and the graft. The suture may hold the ACL in position sothat it may be sutured (using a separate suture) to the graft material,thereby re-attaching the ACL to the femoral arch region. In somevariations the end of the suture is passed through the anchor distally,along the one-way passage through the anchor, holding it in position.This step may be performed to secure the tissue with the anchor evenwhen a graft is not used.

For example, FIGS. 2A-2D illustrate one variation of a method foranchoring a scaffolding (e.g., an ACL graft) and also a method forpositioning a torn ACL next to the anchor and graft so that it can besutured to the graft. Similar steps may be performed even when ascaffold (graft) is not used or connected to the anchor (e.g., theanchor of FIG. 1C). FIGS. 3A-3P show an example of a method forrepairing an ACL, including steps for anchoring the scaffolding/supportin the femoral notch and suturing the ACL to the scaffolding supportwhile the end of the ACL is in the femoral notch.

In FIG. 2A, the anchor, which in this embodiment is shown similar to thevariation of FIGS. 1A and 1B is an ACL screw anchor, may be threadedover a guide wire. Any appropriate guidewire may be used, for example, abeath pin type of guidewire that is known to be used in ACLreconstruction. The guidewire is threaded through the central (one-waysuture passage) of the anchor, and in this variation the guidewire maydisable the one-way cams/tabs within the channel that prevent the suturefrom being pulled proximally when a suture is passed through thechannel. For example, the one-way tabs may fold to allow passage overthe pin/guidewire. As shown in FIGS. 3A-3P, the guidewire or pin may beused to place or position the anchor into a hole formed in the femoralnotch, to place and thereby anchor the ACL graft.

In FIG. 2B, sutures are loaded into the beath pin eyelet and the beathpin (guidewire) is pulled distally through the screw to load the suturesinto the anchor, as shown. In this example, the anchor may already bepositioned within the notch (not shown), and the sutures may already besecured to the end of the ACL. For example, in FIG. 2C, the sutures areloaded into the anchor, and pulling on the sutures to the left (throughthe anchor) pulls the ACL tissue toward the anchor base (the proximalend of the anchor) through the suture channel in the anchor, in aone-way, self-tightening fashion. In this example, the suture channelincludes cams or tabs that allow the suture to be pulled distally butnot proximally, as indicated by the arrow. Eventually, as shown in FIG.2D, the ACL to which the suture is attached will be pulled adjacent tothe proximal end of the anchor (not drawn to scale, as the ACL willtypically be much larger than the anchor). In some variations, the ACLmay be pulled at least partially into the channel formed in the boneinto which the anchor is placed. Once the ACL is pulled (via the suture)adjacent to the anchored scaffolding or graft, it may be sutured to thescaffolding (e.g., graft) using the continuous suture passer, whilepositioned in the femoral notch.

In one variation, the ACL is sutured to the anchor prior to implantingthe anchor in the femoral notch, and the anchor with the end of thefemoral notch is then positioned (e.g., by pulling the anchor using aguidewire and or the suture) into position, where it can be expanded orotherwise fixed into position.

FIGS. 3A-3P illustrate one method for repair of an ACL. In this example,the ACL has ruptured proximally within the femoral notch, and theprocedure is performed within 3 weeks of the injury. FIG. 3A illustratesa portion of the patient's knee, showing the joint between the femur andthe tibia, and in particular illustrating the femoral notch (“notch”).In FIG. 3B the notch is prepared by driving a beath pin into theposterolateral femoral notch, as shown. Alternatively, the region may bedrilled or otherwise penetrated to form a narrow passage through femurhead from the femoral notch. In this example, the beath pin is drivenfrom within the notch and through the femur head region. Anotheralternative variation is shown in FIG. 2B1, in which the beath pin(guidewire) is driven from the outer wall of the femur towards thefemoral notch (inner wall). In this variation, the approach is fromoutside of the femoral notch.

Next, as shown in FIG. 2B, the pin is then over-drilled to form a tunneland/or cavity into which the anchor may be seated; the opening faces thenotch. In this example, the cavity is drilled with a bit that isapproximately one size smaller than the anchor (a screw-type anchor isillustrated here). For example if the outer diameter of the anchor isabout 5-6 mm in diameter, the drill bit diameter may be about 4-5 mm.The depth of drilling may be longer than the length of the anchor. Forexample, in FIG. 3C-3D, the depth of drilling is approximately 25 mm, asshown in FIG. 3D. In variations in which a transosteal tunnel is formedcompletely through the femur, a drill may pass completely through thefemur. The tunnel may be drilled from the notch side (second side of thebone), as shown in FIG. 3C, or the outer side (first side of the bone),as shown in FIG. 3C1.

In some variations, particularly those in which the scaffold (e.g.,graft) attached to the distal tip of the anchor is positioned to theside of the anchor (as illustrated in FIG. 1A), a second cavity may beformed adjacent to the anchor cavity to allow room for the graft. Thisis shown in FIG. 3E. In this example, a dual barrel impacter is driven(e.g., malleted) along the guide wire (beath pin) to create a second,smaller tunnel just superior to the previously drilled hole. This isshown in FIGS. 3F and 3F1. The graft may fit into the adjacent tunnelwithout substantially weakening the attachment of the anchor.

FIG. 3G illustrates the insertion of the knotless screw over the guidewire/pin into the pre drilled hole within the lateral femoral notch; thegraft is inserted into the adjacent channel. The anchor and graft may bepushed or pulled (using the guidewire) into position. For example, apusher may be used to drive the anchor into the channel drilled in thebone. In some variations the anchor is screwed into the channel, overthe guidewire; for example an applicator may removably couple with theproximal end of the anchor and allow it to be inserted into the femur bypushing and/or screwing, particularly in the threaded screw-typeanchors. The graft, which is coupled to the distal end of the anchor,may stay in the adjacent channel as the anchor is inserted; the couplingregion for the scaffold/graft is rotatable relative to the rest of theanchor, thus as the anchor is rotated to insert, the graft may stay inthe channel. As shown in FIG. 3H, the reinforcement graft sits snugglywithin the pre-punched tunnel just superior to the anchor, allowingoptimal in-growth of the graft into the femoral bone.

Once the anchor is secured in the femoral arch, and in variations usinga scaffold/graft, with the graft extending from the arch, the end regionof the ACL may be pulled into position using a suture. Prior to thisstep the ACL may be secured with a suture as shown in FIGS. 4A-4D. InFIG. 4A, the ACL is sutured to securely attach the end of the ACL to adoubled-back suture. In this example a continuous suture passer may beused to pass the midpoint of a free suture around and then through theACL stump, as shown in FIG. 4A. In FIG. 4B, the suture is then fedthrough the loop to secure the tissue in a self-cinching manner, asshown in FIG. 4C. In some variations, this can be done outside of theknee, without tissue interference, because the suture has been insertedinto the knee, passed through the ACL tissue, and removed all throughthe same single pathway. Finally as shown in FIG. 4D, the ligament isnow secured and the sutures are ready to be loaded into the knotlessanchor.

Returning now to FIG. 3I, the suture ends from the previously sewn ACLmay then be fed into the eyelet of the beath pin (which may be doneoutside of the knee), and the beath pin drawn through the anchor (e.g.,pulling distally and/or pushing proximally) to draw the ACL to theproximal end of the anchor and adjacent to the graft, as shown in FIG.3J. For example, the beath pin may then be pulled out from the lateralknee as is typically done with current ACL reconstruction techniques,and the suture follows and is therefore loaded into the anchor. In FIG.3K, both ends of the suture have been withdrawn through the anchordistally by pulling on beath pin (guidewire) as illustrated. Because thesuture channel through the guidewire does not allow the suture(s) to bewithdrawn proximally, either or both ends of the suture may be pulleddistally to draw the end of the ACL near the proximal end of the anchorwithin the bone, and adjacent to the graft.

The ligament can be tensioned by pulling on the sutures with the desiredamount of force. This may reduce the knee (e.g., pulling the tibia backinto position relative to the femur) and may bring the ACL tissue backto its origin on the femoral notch. Thereafter the proximal end of thesuture may be knotted and cut, as shown in FIG. 3M. For example, a small(e.g., 2 mm) incision can be made where the sutures exit the skin andany standard arthroscopic knot cutter can be slid down to the lateralfemur where the sutures can then be safely cut flush with the bone.

Finally, the ACL can be sutured to the graft/support material, as shownin FIGS. 3N to 3P. In this example, the continuous suture passer isbrought in to sew the graft to the ACL to reinforce the repair. Thecontinuous suture passers described herein may be positioned within thenotch and still function to pass a suture through the ACL and the graftmaterial, within the limited space of the notch. The final repair allowsfor a well-tensioned, significantly reinforced ACL repair.

In some variations, platelet-rich plasma or other biologic healingstimulants may also be added following or during the procedure in thenotch. Note that FIGS. 3A-3P are not drawn to scale. For illustrativepurposes, the screw anchor shown in the figures appears larger than theligament in the drawings; in actuality the ligament is likely to beconsiderably larger that the screw.

FIGS. 10A-10K illustrate another variation of a method (and apparatusfor performing the method) of repairing a tissue using a transostealtunnel/anchor. In this example, as above, the tissue being repaired is atorn ACL. As mentioned above, the methods and apparatuses describedherein are not limited to ACL repair, but may be used in other boneregions, particularly joints such as the shoulder, wrist, ankle, andhip.

FIG. 10A shows a front view of a subject's left knee. In this example,some of the tissue (e.g., patellar tendon, patella, etc.) are not shown,for clarity; however, the procedure may be performed with them inposition. The tibia and femur are illustrated, as the femoral notch. TheACL 1001 is shown, and is torn. As discussed above for FIGS. 3B1 and3C1, a tunnel may be formed through the bone, either with or without aguidewire/beath pin. FIG.10B shows the femur with the channel throughthe bone from the outer side (surface) 1005 extending though the femurhead to the inner (notch) side/surface 1007. Thus, the method mayinclude the step of drilling a tunnel (channel) through the bone fromfirst side to second side.

FIG. 10C illustrates the use of a suture passer to secure a suture tothe end of the tissue to be attached to the bone. In this example, thesuture passer is percutaneously inserted into the femoral notch region.The suture passer used is similar to the suture passer described abovein FIGS. 8A-8D. Because the region of the body (e.g., the femoral notchregion) is constrained, and may be otherwise difficult to maneuver, asuture passer capable of operating in such a constricted space with ahigh degree of maneuverability and reliability may be used. For example,in FIG. 10C, the upper jaw member of the suture passer is angled (bypivoting about the proximal elongate body) while the lower jaw isretracted, permitting the upper jaw member to be positioned on one sideof the torn tissue (e.g., ACL). Once the upper jaw is positioned, thelower jaw may be extended, as shown in FIG. 10D, to form a distal-facingjaw around the torn tissue. Having the lower jaw retracted may allow thedistal end of the suture passer to fit into otherwise difficult (orimpossible) to reach regions of the tissue, particularly regions inwhich the tissue (e.g., bone) forms a bottleneck or constricted regionbefore opening up into a larger space, as is the case in the knee. Oncein position around the torn tissue, the suture passer may clamp or holdthe end of the torn tissue (by rotating the upper jaw member against thelower jaw member) and the tissue penetrator may be extended across theopening between the jaws and through the tissue to push a loop (bight)of suture through the tissue. The suture may be attached as illustratedin FIGS. 4A-4D, discussed above, and shown in FIGS. 10E and 10E1. Insome variations the loop of suture 1022 is pulled by the upper jaw andthe ends of the suture may be passed around and through the loop whichis then cinched or tightened onto the tissue, as shown in FIG. 10E1.Thus, the suture may be secured by one or more “locking loops” of suturepassed by the tissue passer. Additional suture stitches may also bepassed to further secure the suture(s) to the torn tissue. The same, ordifferent, sutures (e.g., different lengths of the same suture) may bepassed though/around the torn tissue (e.g., ACL).

Once the suture has been secured to the torn tissue, the free end(s) ofthe one or more sutures may be pulled through the bone tunnel fromsecond (e.g., inner) end of bone tunnel to the first (e.g., outer) endof the bone tunnel, as illustrated in FIG. 10F. In some variations theanchor (a transosteal anchor), which may include a scaffold, asdiscussed above, may have already been passed through the tunnel in thebone and be positioned at the inner end of the bone tunnel (in thisexample, near the femoral notch). The anchor may be locked or otherwisesecured in position so that the suture(s) that attach to the torn tissuemay be passed through the anchor and the bone tunnel.

FIG. 10G shows another alternative, in which the anchor is passed intoand secured to the end of the bone tunnel after the lengths of suturehave been passed through the bone tunnel. In this example, the sutureanchor may be pushed or otherwise driven through the bone tunnel alongthe lengths of suture until it is positioned near the inner face (notchside) facing the torn tissue, as illustrated in FIGS. 10G and 10H. Thus,the step of positioning and/or securing the suture anchor may beperformed either before or after suturing the torn tissue. Oncepositioned, the suture anchor may be locked into place as describedabove.

FIG. 10I shows the suture and torn tendon being secured within theanchor/bone by pulling the suture(s) to cinch the suture and/or tissuesecurely in the suture anchor and thus to and/or in the bone tunnel. Insome variations, the tissue may then be further sutured to a scaffold(e.g., graft) that is secured to the suture anchor and/or the bone. Oncethe torn tissue has been secured as desired, so that the torn tissue isanchored to the bone near the second side of the bone (the side closestto the torn tissue), while allowing the suture to be tightened andadjusted from the opposite side of the bone tunnel (the side furthestfrom the torn tissue).

Once the torn tissue has been repaired, the loose end of the suture maybe cut and/or tied off. FIG. 10J illustrates one variation of the stepof trimming all or some of the suture after it has been cinched and lockinto the anchor to the appropriate degree. In some variations the sutureends are cut and/or tied off from the outer surface of the bone tunnel;in other variations the suture ends are cut and/or tied off from withinthe bone tunnel. For example a suture knot may be pushed down the bonetunnel to knot the suture against the suture anchor.

Thereafter, the bone tunnel may be capped and/or filled, as illustratedin FIG. 10K. For example, the bone tunnel may be filled with a bonefiller such as a bone cement (e.g., PMMA), and/or bone chips (e.g.,xenograft or allograft material), or the like.

In some variations the tunnel through the bone may have a larger outersurface opening than inner surface opening, as illustrated in FIG. 11A.In this example, the access or opening into the tunnel from the femoralnotch side is narrow. This may further assist the anchor in remaining inthe tunnel, though adjacent (within a few mm, e.g., within about 5 mm,within about 4 mm, within about 3 mm, within about 2 mm, within about 1mm, etc.) to the inner bone wall, closest to the tissue to be repaired.In FIG. 11A the tunnel is tapered from a larger diameter to a smallerdiameter. In some variations the tunnel includes one or more “steps” indiameter. As mentioned above, in some variations, this region of thebone tunnel may include additional structures for mating with the sutureanchor to prevent migration of the suture anchor relative to the bone,such as notches, pits, or the like. These structures may be formed by adrill or by a tamp or other bone-shaping device.

FIG. 11B illustrates another variation of a suture anchor that may beused, in particular, with a tunnel having a tapered end as shown in FIG.11A. In this example the anchor includes a central passageway throughwhich the suture may pass. The central passageway may include one ormore one-way locks or other locking elements to prevent the suture frompulling proximally out of the anchor while allowing the suture to bepulling taught distally, through the bone anchor. One end of the anchorin FIG. 11B is tapered to match the taper in the end of the bone tunnel.In use, the anchor may be inserted (tapered end first) through the bonetunnel from the outer surface, driven along the bone tunnel, until thetapered end of the anchor is within the tapered end of the bone tunnel.

EXAMPLE 2 Tibial-Sided Transosteal Anchor for Meniscal Root Repair

In some variation, the methods and apparatuses described herein may beused to treat a torn meniscal root. For example, the meniscal root maybe repaired as described above by forming a transosteal tunnel throughthe tibia (e.g., to the tibial plateau) and repairing the meniscal rootby suturing the torn end of the root and securing it to an anchor heldin tunnel near (e.g., adjacent) to the tibial plateau.

It is well-known in the art that repair of the meniscal root is bothdesirable and highly difficult. For any patient, even “ideal” young andhighly active candidates, meniscal repair continues to represent asignificant challenge. It is undisputed that vertical tears greater than1 cm in the peripheral-third of the meniscus should be repaired,however, there has been new attention on repairing posterior root tears.With these root tear repairs, an inside-out repair is not feasible dueto the posterior midline placement of the needles and the passage of thesuture. Both the medial and lateral menisci have a stout attachment attheir very posterior aspects, which is called the root attachment. Theroot of the meniscus is the region where the meniscus attaches to thecentral tibial plateau. This root attachment is important because itholds the meniscus in place, provides stability to the circumferentialhoop fibers of the meniscus, and prevents meniscal extrusion. When thereis a tear of the meniscal root, it has been demonstrated onbiomechanical testing that it is equivalent to having the whole meniscusremoved. Thus, a tear of the meniscal root is considered a very seriouscondition. An example of a meniscal root repair is shown in FIG. 12A.

Meniscal tears within the body of the meniscus or at the meniscocapsularjunction represent a well-understood and manageable conditionencountered in clinical practice. In comparison, however, meniscal roottears (MRTs) often go unnoticed and represent a unique injury patternwith unique biomechanical consequences. The root attachments of theposterior horns of the medial and lateral meniscus are very importantfor joint health. When these are torn, the loading of the joint isequivalent to having no meniscus on the affected side. Thus, thesepatients can often have early onset arthritis, the development of bonyedema, insufficiency fractures, and the failure of concurrent cruciateligament reconstruction grafts. For this reason, much research has gonein to meniscal root repairs over the last several years. However,current methods for repairing the meniscal root are not completelysatisfactory. For example, meniscal repair techniques that suture themeniscus from the “outside” (e.g., though the capsule) may not properlyrestore the anatomy, for example, anchoring the meniscus to theposterior capsule, rather than the tibia.

For example, FIG. 12A illustrates a torn meniscal root 1201 in the knee.In this example, the femur is not illustrated; in practice the femur maybe positioned over the torn tissue, making it difficult to access, anddifficult to place an anchor near the tibial plateau. Instead, prior tothe invention described herein, the best that could be achieved was tosuture the root and pull the suture (and presumably part of the root)through the trans-tibial tunnel and secure the suture using a button atthe side of the tunnel that is furthest from the tibial plateau. Asdiscussed above, this may allow stretch or creep of the sutures securingthe tissue, weakening the attachment. FIG. 12B shows the tibia in whicha transosteal tunnel has been formed. The tunnel includes an opening1205 on the tibial plateau that connects to an opening on the side ofthe tibia. An anchor may be secured adjacent (e.g., flush with, recessedslightly within or extending slightly from) the tibial plateau. FIGS.12C-12D show an anchor 1209 being secured within the transosteal tunnelthrough the tibia. The anchor may be placed either before, during orafter a suture has been secured to the torn end of the meniscal root.Once the suture has been secured, the meniscal root may be anchored tothe tissue anchor and locked into place, so that the meniscal root isanchored to the tibial plateau again. In this example, the anchor, whichmay be similar to any of the anchors described above, and may includeany of these features, such as the central passageway for passing asuture with one-way locks, may be inserted from the side of thetransosteal tunnel furthest from the torn tissue and passed through thetunnel and anchored near the distal opening 1205. An applicator 1211 maybe used; the applicator may be releasably connected to the anchor andreleased once the anchor is secured in position. For example, theapplicator may connect to the proximal end of the anchor (facing awayfrom the torn tissue). In some variations the applicator may control therelease of anchoring members (e.g., extendable arms, etc.) that help tosecure the anchor in place.

The transosteal tunnel may be positioned with the opening onto theplateau in any appropriate position, including as close to the originallocation of the meniscal root attachment site as reasonable. FIGS.12A-12D are not intended to be representative of the position or thescale.

FIGS. 13A-13E illustrate one method of securing the suture to the tornmeniscal root. In this example, the meniscal root is secured to sutureusing a double locking loop stitch. The root of the meniscus may bearthroscopically repaired using any of the suture passers capable ofminimally invasively (e.g., arthroscopically) and being positioned onboth the superior and inferior sides of the meniscus and passing asuture between the superior and inferior sides. Examples of these suturepassers are described above. In this variation the legs of a loop ofsuture are each passed between the superior and inferior sides (e.g.,from the inferior to the superior side of the meniscus) and then themiddle region between the two is passed to form a loop on the superiorside. The legs of the suture thus extend from the superior side in twodifferent locations (e.g., radially and/or longitudinally spacedlocations) and are pulled though the loop on the superior surface sidethen the loop is cinched (e.g., by pulling on one or both legs) totighten it over the legs. The legs may then be secured to the anchor inthe tibial tunnel. Alternatively, the legs may be passed after the loop(the region of the suture length between the legs) is passed, or thefirst (e.g., distal) leg may be passed, then the loop (the region of thesuture length proximal to the first leg) then the second (e.g.,proximal) leg may be passed. Thus, the order in which the two legs ofthe suture and the loop region between them are passed between the firstand second sides of the tissue may be varied.

In FIG. 13A, the first leg of the suture 1303 has been passed from theinferior to the superior (top, facing) 1301 surface of the meniscus. Asdescribed below, the suture passer may pass a distal “bight” (or loop)of suture by pushing or pulling it through the meniscus once thedistal-facing mouth formed by the two jaws of the suture passer havebeen positioned (e.g., arthroscopically) around the meniscus. Forexample, the suture passer may arthroscopically access the meniscus ofthe knee with a first jaw retracted proximally (relative to theproximal-to-distal long axis of the shaft of the device); the second jawmay be bent or bendable (e.g., pivotable) at the distal end region ofthe shaft of the device. The second jaw may be positioned adjacent tothe superior surface either before or concurrently with sliding thefirst jaw distally to extend it relative to the elongate shaft so thatit is extended adjacent to the inferior surface of the meniscus,positioning the meniscus between the distal-facing jaws. The tissuepenetrator (e.g., needle) may then push or pull the distal end region ofthe suture length through meniscus, e.g., from the inferior to thesuperior surface. If the suture is passed as a loop (e.g., bight) ofsuture, the distal most end of the suture may be drawn through thetissue until just a single-stranded length of the suture (correspondingto the first leg) passes through the tissue.

The second leg (e.g., the proximal end region) of the suture has beenpassed through a radially offset region of the meniscus from theinferior to the superior side as shown in FIG. 13B. In this example, theproximal end region or length 1307 of suture may be loaded on to thesuture passer (or it may have been pre-loaded onto the suture passer)and it is extended (e.g., as a bight or loop) though the meniscus fromthe inferior to the superior surface. The proximal end extendedcompletely out of the meniscus so that both the first leg (the distallength of the suture) and the second leg (the proximal length of thesuture) extend out of the superior side. The region between the firstand second legs, the middle region, is located on the inferior side andmay extend out of the patient, e.g., the access port forarthroscopically accessing the tissue. This central region may then bepassed (as a loop or bight) by the same suture passer from the inferiorto the superior surface of the meniscus, so that a loop 1309 of thecentral region of the length of suture also extends from the superiorsurface of the meniscus, as shown in FIG. 13C. The loop may be passed ina radially intermediate region (between the first and second legs)transversely though the meniscus, as shown. The passage through themeniscus of the loop (and any of the legs) may also be laterally offsetrelative to the legs.

Thereafter, the first and second legs of the suture may be passedthrough the loop on the superior surface, as shown in FIG. 13D. This maybe performed after withdrawing the suture passer, e.g., by a suturegrasping instrument, hook, etc. The loop may then be cinched down overthe legs of the suture, as illustrated in FIG. 13E, and the legs securedto the tibia. This may be done concurrently or separately. By pullingthe legs of the suture, the loop may be cinched down, and the resultingdouble locking loop stitch may hold the end of the meniscus so that itcan both be repositioned and secured relative to the tibial plateau.Additional sutures (including additional locking loop stitches) may beused.

Once secured, the suture(s) may be pulled through the anchor positionedin the tibial tunnel near the opening 1205 and anchored in place. Thefree ends of suture may knotted and/or cut. The tunnel may be filledand/or sealed.

In some variations a combination of a locking loop and a second stitchor loop type may be used (e.g. non-locking loop stitch) to secure orrepair tissue. The second stitch may be any appropriate type of stitch.For example, FIGS. 13F-13G and FIGS. 13H-13I illustrate two alternativemethods in which a locking loop stitch is used with another stitch tosecure a meniscal root. For example, in FIG.13F, the locking loop stitchmay be formed as described and illustrated above in FIGS. 13A-13D;either before, after, or during formation of the locking loop stitch1250, a second stitch, e.g., a simple stitch 1256 may be made throughthe torn meniscal root. In this example, the simple stitch passes fromthe inferior side of the meniscus through the tissue, to the superiorside of the meniscus, across the superior side, and back down throughthe meniscal tissue to the inferior side, as shown. This simple (loop ordouble-pass) stitch may be made with any of the suture devices describedherein. Once the stitch is formed, the loose ends of the stitches (boththe simple stitch and the locking loop stitch) may be pulled andsecured, as illustrated in FIG. 13G. In some variations, it may bebeneficial to provide a combination of a locking loop and simple stitchin order to more securely attach the tissue.

FIG. 13H shows another example of a locking loop stitch 1250 and anotherstitch 1259. As mentioned, the additional stitch may be made before,after, or during formation of the locking loop stitch 1250. In FIG. 13H,the additional stitch is a simple (single loop or one-pass) stitch thattraverses from the inferior side of the meniscus to the superior side ofthe meniscus, and may be formed with any of the suture passer devicesdescribed herein or known. All of the free ends of the stitches may besecured, as indicated in FIG. 13I, e.g., by pulling through an opening,e.g., in a tibial tunnel near the opening 1205 and anchored in place.

FIGS. 14A-14E illustrate another variation of a meniscal root repair. Inthis variation, the perspective view shows the top/superior surface ofthe meniscus as well as the bottom/inferior surface of the meniscus. Atunnel through the tibia 1405 may be formed and an anchor positioned asdescribed above. An access region through the tibia has been formed(tunnel 1405) that may be used to secure the meniscus to the tibialplateau after forming the appropriate locking loop. A suture passer thatis configured so that it can arthroscopically be positioned with a firstjaw adjacent the superior surface and a second jaw adjacent the inferiorsurface and pass a length of suture between the superior and inferiorsurface may be used, and positioned as described above. In this example,the middle region of the length of suture to form the locking loop(double locking look) is passed first, as shown in FIG. 14B. Forsimplicity in all of these figures, the suture passer is notillustrated, but it operated as described below. Thus, a loop of themiddle region 1409 extends from the superior surface as shown. Thesuture length includes a distal region that will form a first leg and aproximal region that will form a second leg and a central region betweenthe two forming the loop. As the central region loop is passed, thedistal and proximal lengths remain outside of the subject, e.g.,extending from the arthroscopic access port in the knee used by thesuture passer. After passing the loop through the meniscus by the suturepasser, the suture passer may be configured so that it releases the loopon the inferior side, allowing it to be repositioned to pass the firstand second legs, while leaving the loop on the superior surface.

In FIG. 14C the first (e.g., distal) leg of the length of suture hasbeen passed through the meniscus from the inferior to superior side, sothat it extends from the superior side. Although only a short length ofloop is shown ending form the superior side of the meniscus, the lengthmay be longer. In addition, the figure does not show the adjacent boneregions (e.g., femur head and tibial plateau) that constrain the accessto the meniscus, however, however they are typically present. Thus, thefree ends of the first and second leg are shown extending away from themeniscus for convenience, in practice, they may be positioned betweenthe superior surface of the meniscus and the femur head.

FIG. 14D shows the second leg after it has been passed by the suturepasser from the inferior to the superior side of the meniscus. Finallyin FIG. 14E, the ends of the first and second leg have been pulledthrough the loop and into the tibial tunnel 1405, so that they can beused to cinch the loop and secured to hold the meniscus in place.Additional sutures (including additional locking loops) may be used.

The ends of the suture may be passed through the tibial tunnel andanchored to a suture anchor secured within the tibial tunnel. In somevariations a guidewire/pin may be used to pull the suture ends thoughtthe tunnel and/or anchor. The anchor may be configured to preventwithdrawal of the suture towards the tibial plateau.

In general, meniscal root repair may require suturing the posterior hornof the meniscus and then anchoring that tissue to the tibia. Traditionalbone anchors are inserted into a bone tunnel from the opening that facesthe tissue to be anchored. This is not possible in root repair as theconstraints within the knee do not allow a straight vector into thetibial plateau at the required insertion point(s). Because of this, thesuture may instead be threaded through the tibial tunnel where it exitsinferiorly along the side of the tibia. It is then placed in tensionaround a button with an O.D. greater than the tunnel I.D. As a result,there are several inches of “free” suture from the meniscal tissue tothe fixation at the button. Under loading, we have observed that thisfree suture stretches. The absolute distance that this free suture canstretch is a function of the length of the free suture. For example,depending on the modulus of elasticity of the suture material, if thefunction is linear and there is a 10% increase in length at a given load(hypothetically), 1 mm of suture will only creep 0.1 mm, but 4 inches ofsuture will stretch 0.4 inches (1 cm). At some point, this stretch maybe clinically significant. The methods and apparatuses described hereinmay allow a substantial reduction in the length of free suture byplacing the transosteal anchor closer to the origin of the tunnel, whichwill provide a more stable and physiological repair.

When a feature or element is herein referred to as being “on” anotherfeature or element, it can be directly on the other feature or elementor intervening features and/or elements may also be present. Incontrast, when a feature or element is referred to as being “directlyon” another feature or element, there are no intervening features orelements present. It will also be understood that, when a feature orelement is referred to as being “connected”, “attached” or “coupled” toanother feature or element, it can be directly connected, attached orcoupled to the other feature or element or intervening features orelements may be present. In contrast, when a feature or element isreferred to as being “directly connected”, “directly attached” or“directly coupled” to another feature or element, there are nointervening features or elements present. Although described or shownwith respect to one embodiment, the features and elements so describedor shown can apply to other embodiments. It will also be appreciated bythose of skill in the art that references to a structure or feature thatis disposed “adjacent” another feature may have portions that overlap orunderlie the adjacent feature.

Terminology used herein is for the purpose of describing particularembodiments only and is not intended to be limiting of the invention.For example, as used herein, the singular forms “a”, “an” and “the” areintended to include the plural forms as well, unless the context clearlyindicates otherwise. It will be further understood that the terms“comprises” and/or “comprising,” when used in this specification,specify the presence of stated features, steps, operations, elements,and/or components, but do not preclude the presence or addition of oneor more other features, steps, operations, elements, components, and/orgroups thereof. As used herein, the term “and/or” includes any and allcombinations of one or more of the associated listed items and may beabbreviated as “/”.

Spatially relative terms, such as “under”, “below”, “lower”, “over”,“upper” and the like, may be used herein for ease of description todescribe one element or feature's relationship to another element(s) orfeature(s) as illustrated in the figures. It will be understood that thespatially relative terms are intended to encompass differentorientations of the device in use or operation in addition to theorientation depicted in the figures. For example, if a device in thefigures is inverted, elements described as “under” or “beneath” otherelements or features would then be oriented “over” the other elements orfeatures. Thus, the exemplary term “under” can encompass both anorientation of over and under. The device may be otherwise oriented(rotated 90 degrees or at other orientations) and the spatially relativedescriptors used herein interpreted accordingly. Similarly, the terms“upwardly”, “downwardly”, “vertical”, “horizontal” and the like are usedherein for the purpose of explanation only unless specifically indicatedotherwise.

Although the terms “first” and “second” may be used herein to describevarious features/elements, these features/elements should not be limitedby these terms, unless the context indicates otherwise. These terms maybe used to distinguish one feature/element from another feature/element.Thus, a first feature/element discussed below could be termed a secondfeature/element, and similarly, a second feature/element discussed belowcould be termed a first feature/element without departing from theteachings of the present invention.

As used herein in the specification and claims, including as used in theexamples and unless otherwise expressly specified, all numbers may beread as if prefaced by the word “about” or “approximately,” even if theterm does not expressly appear. The phrase “about” or “approximately”may be used when describing magnitude and/or position to indicate thatthe value and/or position described is within a reasonable expectedrange of values and/or positions. For example, a numeric value may havea value that is +/−0.1% of the stated value (or range of values), +/−1%of the stated value (or range of values), +/−2% of the stated value (orrange of values), +/−5% of the stated value (or range of values), +/−10%of the stated value (or range of values), etc. Any numerical rangerecited herein is intended to include all sub-ranges subsumed therein.

Although various illustrative embodiments are described above, any of anumber of changes may be made to various embodiments without departingfrom the scope of the invention as described by the claims. For example,the order in which various described method steps are performed mayoften be changed in alternative embodiments, and in other alternativeembodiments one or more method steps may be skipped altogether. Optionalfeatures of various device and system embodiments may be included insome embodiments and not in others. Therefore, the foregoing descriptionis provided primarily for exemplary purposes and should not beinterpreted to limit the scope of the invention as it is set forth inthe claims.

The examples and illustrations included herein show, by way ofillustration and not of limitation, specific embodiments in which thesubject matter may be practiced. As mentioned, other embodiments may beutilized and derived there from, such that structural and logicalsubstitutions and changes may be made without departing from the scopeof this disclosure. Such embodiments of the inventive subject matter maybe referred to herein individually or collectively by the term“invention” merely for convenience and without intending to voluntarilylimit the scope of this application to any single invention or inventiveconcept, if more than one is, in fact, disclosed. Thus, althoughspecific embodiments have been illustrated and described herein, anyarrangement calculated to achieve the same purpose may be substitutedfor the specific embodiments shown. This disclosure is intended to coverany and all adaptations or variations of various embodiments.Combinations of the above embodiments, and other embodiments notspecifically described herein, will be apparent to those of skill in theart upon reviewing the above description.

What is claimed is:
 1. A method of arthroscopically repairing a tornmeniscal root with a first suture and a second suture, the methodcomprising: arthroscopically passing a first locking loop stitch throughthe meniscal tissue with a suture passer, by passing a loop of the firstsuture from a first side of the meniscal tissue to a second side of themeniscal tissue, passing a first end region of the first suture distalto the loop through the meniscal tissue and through the loop, andpassing a second end region of the first suture proximal to the loopthrough the meniscal tissue and through the loop, and cinching the loopclosed; and forming a second suture stitch by pulling the second suturebetween the first side of the meniscal tissue and the second side of themeniscal tissue so that a distal end region and a proximal end region ofthe second suture extend from the meniscal tissue; and anchoring theproximal and distal end regions of the second suture and the first andsecond end regions of the first suture.
 2. The method of claim 1,further comprising forming a passage through either the tibia or thefemur; and pulling the proximal and distal end regions of the secondsuture and the first and second end regions of the first suture throughthe passage.
 3. The method of claim 1, wherein arthroscopically passingthe first locking loop stitch comprises passing the loop from aninferior to a superior surface of a meniscus with the suture passer. 4.The method of claim 1, further comprising arthroscopically positioningthe suture passer with a first jaw between a superior surface of ameniscus and a femur and a second jaw between an inferior surface and atibia.